Did expansion of health insurance coverage reduce horizontal inequity in healthcare finance? A decomposition analysis for China

OBJECTIVES

'Horizontal inequity' in healthcare finance occurs when people with equal income contribute unequally to healthcare payments. Prior research is lacking on horizontal inequity in China. Accordingly, this study set out to examine horizontal inequity in the Chinese healthcare financing system in 2002 and 2007 through two rounds of national household health surveys.

DESIGN

Two rounds of cross-sectional study.

SETTING

Heilongjiang Province, China.

PARTICIPANTS

Adopting a multistage stratified random sampling, 3841 households with 11 572 individuals in 2003 and 5530 households with 15 817 individuals in 2008 were selected.

METHODS

The decomposition method of Aronson et al was used in the present study to measure the redistributive effects and horizontal inequity in healthcare finance.

FINDINGS

Over the period 2002-2007, the absolute value of horizontal inequity in total healthcare payments decreased from 93.85 percentage points to 35.50 percentage points in urban areas, and from 113.19 percentage points to 37.12 percentage points in rural areas. For public health insurance, it increased from 17.84 percentage points to 28.02 percentage points in urban areas, and decreased from 127.93 percentage points to 0.36 percentage points in rural areas. Horizontal inequity in out-of-pocket payments decreased from 79.92 percentage points to 24.83 percentage points in urban areas, and from 127.71 percentage points to 53.10 percentage points in rural areas.

CONCLUSIONS

Our results show that horizontal inequity in total healthcare financing decreased over the period 2002-2007 in China. In addition, out-of-pocket payments contributed most to the extent of horizontal inequity, which were reduced both in urban and rural areas over the period 2002-2007.

An Exploratory Study: A Head-to-Head Comparison of the EQ-5D-5L and AQoL-8D for Long-Term Publicly Waitlisted Bariatric Surgery Patients Before and 3 Months After Bariatric Surgery

BACKGROUND

Choice of a multi-attribute utility instrument (MAUI) that appropriately assesses an intervention's health-related quality-of-life (HRQoL) impacts is a vital part of healthcare resource allocation and clinical assessment.

OBJECTIVE

Our exploratory study compared the EuroQol (EQ)-5D-5L and Assessment of Quality of Life (AQoL)-8D MAUIs, which were used to assess the effect of bariatric surgery for a cohort of long-term publicly waitlisted, severely obese patients.

METHODS

The study was conducted at the Hobart Private Hospital (Tasmania, Australia). To compare the sensitivity and instrument content of the two MAUIs, we used dimensional comparisons by investigating the distribution of patient-reported responses (number/percentage) across the MAUIs' levels and dimensions; summary health-state utility valuations (utilities); and individual/super-dimension scores (AQoL-8D) to investigate discriminatory power and HRQoL improvements preoperatively and 3 months postoperatively.

RESULTS

Participants' (n = 23) overall MAUI completion rate was 74%. Postoperative total weight loss was 9.9%. EQ-5D-5L utilities were relatively higher pre- and postoperatively than AQoL-8D utilities [mean standard deviation (SD) EQ-5D-5L 0.70 (0.25) to 0.80 (0.25); AQoL-8D 0.51 (0.24) to 0.61 (0.24)]. AQoL-8D Psychosocial super dimension was relatively low postoperatively [0.37 (0.25)], driving the instrument's lower utility. These results were supported by the dimensional comparisons that revealed an overall greater dispersion for the AQoL-8D. Nevertheless, there were clinical improvements in utilities for both instruments. AQoL-8D utilities were lower than population norms; not so the EQ-5D-5L utilities. The AQoL-8D dimensions of Happiness, Coping, and Self-worth improved the most.

CONCLUSIONS

AQoL-8D more fully captured the impact of obesity and bariatric surgery on HRQoL (particularly psychosocial impacts) for long-term waitlisted bariatric surgery patients, even 3 months postoperatively. AQoL-8D preoperative utility revealed our population's HRQoL was lower than people with cancer or heart disease.

Effects of multiple sclerosis disease-modifying therapies on employment measures using patient-reported data

BACKGROUND

The direct comparative evidence on treatment effects of available multiple sclerosis (MS) disease-modifying therapies (DMTs) is limited, and few studies have examined the benefits of DMTs on employment outcomes. We compared the effects of DMTs used in the previous 5 years on improving the work attendance, amount of work and work productivity of people with MS.

METHODS

The Australian MS Longitudinal Study collected data from participants on DMTs usage from 2010 to 2015 and whether DMTs contributed to changes in employment outcomes. We classified 11 DMTs into three categories based on their clinical efficacy (β-interferons and glatiramer acetate as category 1; teriflunomide and dimethyl fumarate as category 2; fingolimod, natalizumab, alemtuzumab and mitoxantrone as category 3). Each DMT used by a participant was treated as one observation and analysed by log-multinomial regression.

RESULTS

Of the 874 participants included, 1384 observations were generated. Those who used category 3 (higher efficacy) DMTs were 2-3 times more likely to report improvements in amount of work, work attendance and work productivity compared with those who used category 1 (classical injectable) DMTs. Natalizumab was associated with superior beneficial effects on patient-reported employment outcomes than fingolimod (RR=1.76, 95% CI 1.02 to 3.03 for increased work attendance and RR=1.46, 95% CI 1.02 to 2.10 for increased work productivity).

CONCLUSIONS

Those using the higher efficacy (category 3) DMTs, particularly fingolimod and natalizumab, reported significant increases in amount of work, work attendance and work productivity, suggesting they have important beneficial effects on work life in people with MS.

Estimation of annual probabilities of changing disability levels in Australians with relapsing-remitting multiple sclerosis

BACKGROUND

Transition probabilities are the engine within many health economics decision models. However, the probabilities of progression of disability due to multiple sclerosis (MS) have not previously been estimated in Australia.

OBJECTIVES

To estimate annual probabilities of changing disability levels in Australians with relapsing-remitting MS (RRMS).

METHODS

Combining data from Ausimmune/Ausimmune Longitudinal (2003-2011) and Tasmanian MS Longitudinal (2002-2005) studies (n = 330), annual transition probabilities were obtained between no/mild (Expanded Disability Status Scale (EDSS) levels 0-3.5), moderate (EDSS 4-6.0) and severe (EDSS 6.5-9.5) disability.

RESULTS

From no/mild disability, 6.4% (95% confidence interval (CI): 4.7-8.4) and 0.1% (0.0-0.2) progressed to moderate and severe disability annually, respectively. From moderate disability, 6.9% (1.0-11.4) improved (to no/mild state) and 2.6% (1.1-4.5) worsened. From severe disability, 0.0% improved to moderate and no/mild disability. Male sex, age at onset, longer disease duration, not using immunotherapies greater than 3 months and a history of relapse were related to higher probabilities of worsening.

CONCLUSION

We have estimated probabilities of changing disability levels in Australians with RRMS. Probabilities differed between various subgroups, but due to small sample sizes, results should be interpreted with caution. Our findings will be helpful in predicting long-term disease outcomes and in health economic evaluations of MS.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics

Obesity is an economic problem. Bariatric surgery is cost-effective for severe and resistant obesity. Most economic evaluations of bariatric surgery use administrative data and narrowly defined direct medical costs in their quantitative analyses. Demand far outstrips supply for bariatric surgery. Further allocation of health care resources to bariatric surgery (particularly public) could be stimulated by new health economic evidence that supports the provision of bariatric surgery. We postulated that qualitative research methods would elicit important health economic dimensions of bariatric surgery that would typically be omitted from the current economic evaluation framework, nor be reported and therefore not considered by policymakers with sufficient priority. We listened to patients: Focus group data were analysed thematically with software assistance. Key themes were identified inductively through a dialogue between the qualitative data and pre-existing economic theory (perspective, externalities, and emotional capital). We identified the concept of emotional capital where participants described life-changing desires to be productive and participate in their communities postoperatively. After self-funding bariatric surgery, some participants experienced financial distress. We recommend a mixed-methods approach to the economic evaluation of bariatric surgery. This could be operationalised in health economic model conceptualisation and construction, through to the separate reporting of qualitative results to supplement quantitative results.

Estimating MS-related work productivity loss and factors associated with work productivity loss in a representative Australian sample of people with multiple sclerosis

Background:

Little is known about the work productivity loss in multiple sclerosis (MS).

Objectives:

To quantify the MS-related work productivity loss and to compare factors associated with labour force participation and work productivity loss.

Methods:

Participants were from the Australian MS Longitudinal Study. MS-related work productivity loss included absenteeism (time missed from work) and presenteeism (reduced productivity while working). Data were analysed using log-binomial and Cragg hurdle regression.

Results:

Among 740 MS employees, 56% experienced any work productivity loss due to MS in the past 4  weeks. The mean total work productivity loss was 2.5  days (14.2% lost productive time), absenteeism 0.6  days (3.4%) and presenteeism 1.9  days (10.8%)), leading to AU$6767 (US$4985, EURO€4578) loss per person annually. Multivariable analyses showed that work productivity was determined most strongly by symptoms, particularly ‘fatigue and cognitive symptoms’ and ‘pain and sensory symptoms’, while older age, and lower education level were also predictive of not being in the labour force.

Conclusion:

MS-related presenteeism was three times higher than absenteeism, highlighting the importance of presenteeism being included in employment outcomes. The dominance of symptom severity as predictors of both work participation and productivity loss emphasises the need for improved management of symptoms.

Computer Modeling of Diabetes and Its Transparency: A Report on the Eighth Mount Hood Challenge

OBJECTIVES

The Eighth Mount Hood Challenge (held in St. Gallen, Switzerland, in September 2016) evaluated the transparency of model input documentation from two published health economics studies and developed guidelines for improving transparency in the reporting of input data underlying model-based economic analyses in diabetes.

METHODS

Participating modeling groups were asked to reproduce the results of two published studies using the input data described in those articles. Gaps in input data were filled with assumptions reported by the modeling groups. Goodness of fit between the results reported in the target studies and the groups' replicated outputs was evaluated using the slope of linear regression line and the coefficient of determination (R²). After a general discussion of the results, a diabetes-specific checklist for the transparency of model input was developed.

RESULTS

Seven groups participated in the transparency challenge. The reporting of key model input parameters in the two studies, including the baseline characteristics of simulated patients, treatment effect and treatment intensification threshold assumptions, treatment effect evolution, prediction of complications and costs data, was inadequately transparent (and often missing altogether). Not surprisingly, goodness of fit was better for the study that reported its input data with more transparency. To improve the transparency in diabetes modeling, the Diabetes Modeling Input Checklist listing the minimal input data required for reproducibility in most diabetes modeling applications was developed.

CONCLUSIONS

Transparency of diabetes model inputs is important to the reproducibility and credibility of simulation results. In the Eighth Mount Hood Challenge, the Diabetes Modeling Input Checklist was developed with the goal of improving the transparency of input data reporting and reproducibility of diabetes simulation model results.

An Exploratory Study of Long-Term Publicly Waitlisted Bariatric Surgery Patients' Quality of Life Before and 1 Year After Bariatric Surgery, and Considerations for Healthcare Planners

BACKGROUND

Long-term publicly waitlisted bariatric surgery patients typically experience debilitating physical/psychosocial obesity-related comorbidities that profoundly affect their quality of life.

OBJECTIVES

We sought to measure quality-of-life impacts in a study population of severely obese patients who had multiyear waitlist times and then underwent bariatric surgery.

METHODS

Participants were recruited opportunistically following a government-funded initiative to provide bariatric surgery to morbidly obese long-term waitlisted patients. Participants self-completed the EQ-5D-5L and AQoL-8D questionnaires pre- and postoperatively. Utility valuations (utilities) and individual/super dimension scores (AQoL-8D only) were generated.

RESULTS

Participants' (n = 23) waitlisted time was mean [standard deviation (SD)] 6.5 (2) years, body mass index reduced from 49.3 (9.35) kg/m² preoperatively to 40.8 (7.01) 1 year postoperatively (p = 0.02). One year utilities revealed clinical improvements (both instruments). AQoL-8D improved significantly from baseline to 1 year, with the change twice that of the EQ-5D-5L [EQ-5D-5L: mean (SD) 0.70 (0.25) to 0.78 (0.25); AQoL-8D: 0.51 (0.24) to 0.67 (0.23), p = 0.04], despite the AQoL-8D's narrower algorithmic range. EQ-5D-5L utility plateaued from 3 months to 1 year. AQoL-8D 1-year utility improvements were driven by Happiness/Coping/Self-worth (p < 0.05), and the Psychosocial super dimension score almost doubled at 1 year (p < 0.05). AQoL-8D revealed a wider dispersion of individual utilities.

CONCLUSIONS

Ongoing improvements in psychosocial parameters from 3 months to 1 year post-surgery accounted for improvements in overall utilities measured by the AQoL-8D that were not detected by EQ-5D-5L. Selection of a sensitive instrument is important to adequately assess changes in quality of life and to accurately reflect changes in quality-adjusted life-years for cost-utility analyses and resource allocation in a public healthcare resource-constrained environment.

A Systematic Review of Cost-of-Illness Studies of Multimorbidity

OBJECTIVES

The economic burden of multimorbidity is considerable. This review analyzed the methods of cost-of-illness (COI) studies and summarized the economic outcomes of multimorbidity.

METHODS

A systematic review (2000-2016) was performed, which was registered with Prospero, reported according to PRISMA, and used a quality checklist adapted for COI studies. The inclusion criteria were peer-reviewed COI studies on multimorbidity, whereas the exclusion criterion was studies focusing on an index disease. Extracted data included the definition, measure, and prevalence of multimorbidity; the number of included health conditions; the age of study population; the variables used in the COI methodology; the percentage of multimorbidity vs. total costs; and the average costs per capita.

RESULTS

Among the 26 included articles, 14 defined multimorbidity as a simple count of 2 or more conditions. Methodologies used to derive the costs were markedly different. Given different healthcare systems, OOP payments of multimorbidity varied across countries. In the 17 and 12 studies with cut-offs of ≥2 and ≥3 conditions, respectively, the ratios of multimorbidity to non-multimorbidity costs ranged from 2-16 to 2-10. Among the ten studies that provided cost breakdowns, studies with and without a societal perspective attributed the largest percentage of multimorbidity costs to social care and inpatient care/medicine, respectively.

CONCLUSION

Multimorbidity was associated with considerable economic burden. Synthesising the cost of multimorbidity was challenging due to multiple definitions of multimorbidity and heterogeneity in COI methods. Count method was most popular to define multimorbidity. There is consistent evidence that multimorbidity was associated with higher costs.

Population estimates and characteristics of Australians potentially eligible for bariatric surgery: findings from the 2011–13 Australian Health Survey

Objective The aim of the present study was to determine the potential demand for publicly and privately funded bariatric surgery in Australia. Methods Nationally representative data from the 2011–13 Australian Health Survey were used to estimate the numbers and characteristics of Australians meeting specific eligibility criteria as recommended in National Health and Medical Research Council guidelines for the management of overweight and obesity. Results Of the 3 352 037 adult Australians (aged 18–65 years) estimated to be obese in 2011–13, 882 441 (26.3%; 95% confidence interval (CI) 23.0–29.6) were potentially eligible for bariatric surgery (accounting for 6.2% (95% CI 5.4–7.1) of the adult population aged 18–65 years (n = 14 122 020)). Of these, 396 856 (45.0%; 95% CI 40.4–49.5) had Class 3 obesity (body mass index (BMI) ≥40 kg m–2), 470945 (53.4%; 95% CI 49.0–57.7) had Class 2 obesity (BMI 35–39.9 kg m–2) with obesity-related comorbidities or risk factors and 14 640 (1.7%; 95% CI 0.6–2.7) had Class 1 obesity (BMI 30–34.9 kg m–2) with poorly controlled type 2 diabetes and increased cardiovascular risk; 458 869 (52.0%; 95% CI 46.4–57.6) were female, 404 594 (45.8%; 95% CI 37.3–54.4) had no private health insurance and 309 983 (35.1%; 95% CI 28.8–41.4) resided outside a major city. Conclusion Even if only 5% of Australian adults estimated to be eligible for bariatric surgery sought this intervention, the demand, particularly in the public health system and outside major cities, would far outstrip current capacity. Better guidance on patient prioritisation and greater resourcing of public surgery are needed. What is known about this topic? In the period 2011–13, 4 million Australian adults were estimated to be obese, with obesity disproportionately more prevalent in areas of socioeconomic disadvantage. Bariatric surgery is considered to be cost-effective and the most effective treatment for adults with obesity, but is mainly privately funded in Australia (>90%), with 16 650 primary privately funded procedures performed in 2015. The extent to which the supply of bariatric surgery is falling short of demand in Australia is unknown. What does this paper add? The present study provides important information for health service planners. For the first time, population estimates and characteristics of those potentially eligible for bariatric surgery in Australia have been described based on the best available evidence, using categories that best approximate the national recommended eligibility criteria. What are the implications for practitioners? Even if only 5% of those estimated to be potentially eligible for bariatric surgery in Australia sought a surgical pathway (44 122 of 882 441), the potential demand, particularly in the public health system and outside major cities, would still far outstrip current capacity, underscoring the immediate need for better guidance on patient prioritisation. The findings of the present study provide a strong signal that more funding of public surgery and other effective interventions to assist this population group are necessary.

Improving equity in health care financing in China during the progression towards Universal Health Coverage

BACKGROUND

China is reforming the way it finances health care as it moves towards Universal Health Coverage (UHC) after the failure of market-oriented mechanisms for health care. Improving financing equity is a major policy goal of health care system during the progression towards universal coverage.

METHODS

We used progressivity analysis and dominance test to evaluate the financing channels of general taxation, pubic health insurance, and out-of-pocket (OOP) payments. In 2012 a survey of 8854 individuals in 3008 households recorded the socioeconomic and demographic status, and health care payments of those households.

RESULTS

The overall Kakwani index (KI) of China's health care financing system is 0.0444. For general tax KI was -0.0241 (95% confidence interval (CI): -0.0315 to -0.0166). The indices for public health schemes (Urban Employee Basic Medical Insurance, Urban Resident's Basic Medical Insurance, New Rural Cooperative Medical Scheme) were respectively 0.1301 (95% CI: 0.1008 to 0.1594), -0.1737 (95% CI: -0.2166 to -0.1308), and -0.5598 (95% CI: -0.5830 to -0.5365); and for OOP payments KI was 0.0896 (95%CI: 0.0345 to 0.1447). OOP payments are still the dominant part of China's health care finance system.

CONCLUSION

China's health care financing system is not really equitable. Reducing the proportion of indirect taxes would considerably improve health care financing equity. The flat-rate contribution mechanism is not recommended for use in public health insurance schemes, and more attention should be given to optimizing benefit packages during China's progression towards UHC.

Re-operations after Secondary Bariatric Surgery: a Systematic Review

This paper reviews reoperations rates for short- and long-term complications following secondary bariatric procedures and need for further bariatric surgery. The search revealed 28 papers (1317 secondary cases) following at least 75 % of patients for 12 months or more. For adjustable gastric banding (AGB), rebanding had higher re-revisional rates than conversions into other procedures. Conversion of AGB to Roux-en-Y gastric bypass had the highest number of short- (10.7 %) and long-term (22.0 %) complications. We estimated 194 additional reoperations per 1000 patients having a secondary procedure, 8.8 % needing tertiary surgery. Despite being poorly reported, risks of reoperations for long-term complications and tertiary bariatric surgery are higher than usually reported risks of short-term complications and should be taken into account when choosing a secondary bariatric procedure and for economic evaluations.

Cost-Effectiveness of Different Population Screening Strategies for Hereditary Haemochromatosis in Australia

INTRODUCTION

Amongst populations of northern European ancestry, HFE-associated haemochromatosis is a common genetic disorder characterised by iron overload. In the absence of treatment, excess iron is stored in parenchymal tissues, causing morbidity and mortality. Population screening programmes may increase early diagnosis and reduce associated disease. No contemporary health economic evaluation has been published for Australia. The objective of this study was to identify cost-effective screening strategies for haemochromatosis in the Australian setting.

METHODS

A Markov model using probabilistic decision analysis was developed comparing four adult screening strategies: the status quo (cascade and incidental screening), genotyping with blood and buccal samples and transferrin saturation followed by genotyping (TfS). Target populations were males (30 years) and females (45 years) of northern European ancestry. Cost-effectiveness was estimated from the government perspective over a lifetime horizon.

RESULTS

All strategies for males were cost-effective compared to the status quo. The incremental costs (standard deviation) associated with genotyping (blood) were AUD7 (56), TfS AUD15 (45) and genotyping (buccal) AUD63 (56), producing ICERs of AUD1673, 4103 and 15,233/quality-adjusted life-year (QALY) gained, respectively. For females, only the TfS strategy was cost-effective, producing an ICER of AUD10,195/QALY gained. Approximately 3% of C282Y homozygotes were estimated to be identified with the status quo approach, compared with 40% with the proposed screening strategies.

CONCLUSION

This model estimated that genotyping and TfS strategies are likely to be more cost-effective screening strategies than the status quo.

Establishing benchmark EQ-5D-3L population health state utilities and identifying their correlates in Gansu Province, China

PURPOSES

Despite a flurry of cost utility analyses conducted in the Chinese population in recent years, a standard set of health state utilities (HSUs) for the Chinese population is lacking. The aims of this study were to (1) determine benchmark age- and sex-specific HSUs for a Chinese population, and (2) assess key correlates of HSUs in this population.

METHODS

Quality-of-life was evaluated using the validated EQ-5D-3L questionnaire. HSUs were calculated using data collected from Gansu Province (n = 9833). Overall differences in HSUs were analysed using linear regression and a two-tailed p value <0.05 was determined to be statistically significant. The minimal difference in weighted index was set at 0.074.

RESULTS

HSUs decreased with age in both males and females. Living in the non-capital areas, being separated/divorced/widowed or never married, being never educated, diagnosed with chronic disease, and no regular physical activity were associated with lower HSUs. HSUs for women were lower than for men in univariate regression analysis; however, no differences were found after adjusting for other covariates. In addition, the difference in HSU reached the level of minimal difference in weighted index for participants with chronic disease. HSUs for those who were diagnosed with chronic disease were 0.098 (0.092-0.104) lower than those without chronic disease.

CONCLUSIONS

This study reports HSUs for a Chinese population in Gansu and investigates the key correlates of HSUs in this population. In addition, the use of EQ-5D-3L in assessing population health is limited given the high ceiling effect and skewed HSUs.

Population Screening for Hereditary Haemochromatosis in Australia: Construction and Validation of a State-Transition Cost-Effectiveness Model

INTRODUCTION

HFE-associated haemochromatosis, the most common monogenic disorder amongst populations of northern European ancestry, is characterised by iron overload. Excess iron is stored in parenchymal tissues, leading to morbidity and mortality. Population screening programmes are likely to improve early diagnosis, thereby decreasing associated disease. Our aim was to develop and validate a health economics model of screening using utilities and costs from a haemochromatosis cohort.

METHODS

A state-transition model was developed with Markov states based on disease severity. Australian males (aged 30 years) and females (aged 45 years) of northern European ancestry were the target populations. The screening strategy was the status quo approach in Australia; the model was run over a lifetime horizon. Costs were estimated from the government perspective and reported in 2015 Australian dollars ($A); costs and quality-adjusted life-years (QALYs) were discounted at 5% annually. Model validity was assessed using goodness-of-fit analyses. Second-order Monte-Carlo simulation was used to account for uncertainty in multiple parameters.

RESULTS

For validity, the model reproduced mortality, life expectancy (LE) and prevalence rates in line with published data. LE for C282Y homozygote males and females were 49.9 and 40.2 years, respectively, slightly lower than population rates. Mean (95% confidence interval) QALYS were 15.7 (7.7-23.7) for males and 14.4 (6.7-22.1) for females. Mean discounted lifetime costs for C282Y homozygotes were $A22,737 (3670-85,793) for males and $A13,840 (1335-67,377) for females. Sensitivity analyses revealed discount rates and prevalence had the greatest impacts on outcomes.

CONCLUSION

We have developed a transparent, validated health economics model of C282Y homozygote haemochromatosis. The model will be useful to decision makers to identify cost-effective screening strategies.

The support needs of patients waiting for publicly funded bariatric surgery - implications for health service planners

The objective of this study was to investigate the experience of waiting for publicly funded bariatric surgery in an Australian tertiary healthcare setting. Focus groups and individual interviews involving people waiting for or who had undergone publicly funded bariatric surgery were audio-recorded, transcribed and analysed thematically. A total of 11 women and 6 men engaged in one of six focus groups in 2014, and an additional 10 women and 9 men were interviewed in 2015. Mean age was 53 years (range 23-66); mean waiting time was 6 years (range 0-12), and mean time since surgery was 4 years (range 0-11). Waiting was commonly reported as emotionally challenging (e.g. frustrating, depressing, stressful) and often associated with weight gain (despite weight-loss attempts) and deteriorating physical health (e.g. development of new or worsening obesity-related comorbidity or decline in mobility) or psychological health (e.g. development of or worsening depression). Peer support, health and mental health counselling, integrated care and better communication about waitlist position and management (e.g. patient prioritization) were identified support needs. Even if wait times cannot be reduced, better peer and health professional supports, together with better communication from health departments, may improve the experience or outcomes of waiting and confer quality-of-life gains irrespective of weight loss.

Has equity in government subsidy on healthcare improved in China? Evidence from the China's National Health Services Survey

Background

Monitoring the equity of government healthcare subsidies (GHS) is critical for evaluating the performance of health policy decisions. China’s low-income population encounters barriers in accessing benefits from GHS. This paper focuses on the distribution of China’s healthcare subsidies among different socio-economic populations and the factors that affect their equitable distribution. It examines the characteristics of equitable access to benefits in a province of northeastern China, comparing the equity performance between urban and rural areas.

Methods

Benefit incidence analysis was applied to GHS data from two rounds of China’s National Health Services Survey (2003 and 2008, N = 27,239) in Heilongjiang province, reflecting the information in 2002 and 2007 respectively. Concentration index (CI) was used to evaluate the absolute equity of GHSs in outpatient and inpatient healthcare services. A negative CI indicates disproportionate concentration of GHSs among the poor, while a positive CI indicates the GHS is pro-rich, a CI of zero indicates perfect equity. In addition, Kakwani index (KI) was used to evaluate the progressivity of GHSs. A positive KI denotes the GHS is regressive, while a negative value denotes the GHS is progressive.

Results

CIs for inpatient care in urban and rural residents were 0.2036 and 0.4497 respectively in 2002, and those in 2007 were 0.4433 and 0.5375. Likewise, CIs for outpatient care are positive in both regions in 2002 and 2007, indicating that both inpatient and outpatient GHSs were pro-rich in both survey periods irrespective of region. In addition, KIs for inpatient services were −0.3769 (urban) and 0.0576 (rural) in 2002 and those in 2007 were 0.0280 and 0.1868. KIs for outpatient service were -0.4278 (urban) and -0.1257 (rural) in 2002, those in 2007 were −0.2572 and −0.1501, indicating that equity was improved in GHS in outpatient care in both regions but not in inpatient services.

Conclusions

The benefit distribution of government healthcare subsidies has been strongly influenced by China’s health insurance schemes. Their compensation policies and benefit packages need reform to improve the benefit equity between outpatient and inpatient care both in urban and rural areas.

Multimorbidity and health-related quality of life (HRQoL) in a nationally representative population sample: implications of count versus cluster method for defining multimorbidity on HRQoL

Background

No universally accepted definition of multimorbidity (MM) exists, and implications of different definitions have not been explored. This study examined the performance of the count and cluster definitions of multimorbidity on the sociodemographic profile and health-related quality of life (HRQoL) in a general population.

Methods

Data were derived from the nationally representative 2007 Australian National Survey of Mental Health and Wellbeing (n = 8841). The HRQoL scores were measured using the Assessment of Quality of Life (AQoL-4D) instrument. The simple count (2+ & 3+ conditions) and hierarchical cluster methods were used to define/identify clusters of multimorbidity. Linear regression was used to assess the associations between HRQoL and multimorbidity as defined by the different methods.

Results

The assessment of multimorbidity, which was defined using the count method, resulting in the prevalence of 26% (MM2+) and 10.1% (MM3+). Statistically significant clusters identified through hierarchical cluster analysis included heart or circulatory conditions (CVD)/arthritis (cluster-1, 9%) and major depressive disorder (MDD)/anxiety (cluster-2, 4%). A sensitivity analysis suggested that the stability of the clusters resulted from hierarchical clustering. The sociodemographic profiles were similar between MM2+, MM3+ and cluster-1, but were different from cluster-2. HRQoL was negatively associated with MM2+ (β: −0.18, SE: −0.01, p < 0.001), MM3+ (β: −0.23, SE: −0.02, p < 0.001), cluster-1 (β: −0.10, SE: 0.01, p < 0.001) and cluster-2 (β: −0.36, SE: 0.01, p < 0.001).

Conclusions

Our findings confirm the existence of an inverse relationship between multimorbidity and HRQoL in the Australian population and indicate that the hierarchical clustering approach is validated when the outcome of interest is HRQoL from this head-to-head comparison. Moreover, a simple count fails to identify if there are specific conditions of interest that are driving poorer HRQoL. Researchers should exercise caution when selecting a definition of multimorbidity because it may significantly influence the study outcomes.

Costs associated with hereditary haemochromatosis in Australia: a cost-of-illness study

Objective The aim of the present study was to assess health sector, other sector and time-related (productivity) costs associated with hereditary haemochromatosis from societal, government and patient perspectives for the Australian setting. Methods A national web-based survey of people with haemochromatosis was conducted between November 2013 and February 2015. Participants completed a health survey and resource use diaries. Costs were calculated using a bottom-up approach and calculated in 2015 Australian dollars. Results Cost data were available for 157 participants. From a societal perspective, the estimated annual cost of haemochromatosis was A$274 million. The mean (95% confidence interval) cost for symptomatic patients was almost threefold greater than that of asymptomatic patients (A$10030 (7705–12670) vs A$3701 (2423–5296) respectively). Health sector and productivity-related time loss were the main cost drivers. When extrapolating costs to the Australian population level, asymptomatic haemochromatosis accounted for higher costs than symptomatic haemochromatosis (A$183 million vs A$91 million), reflecting the low clinical penetrance estimate used. Total costs increased when higher clinical penetrance estimates were used. Conclusion The present cost-of-illness study, the first to be published for haemochromatosis, found that although costs were substantial, they could be decreased by reducing clinical penetrance. Development of cost-effective strategies to increase early diagnosis is likely to result in better health outcomes for patients and lower total costs. What is known about the topic? To date, no cost-of-illness study has been conducted for haemochromatosis. Previous economic work in this area has relied on cost estimates based on expert opinion. What does the paper add? This paper provides the first cost estimates for haemochromatosis for the Australian population. These estimates, calculated using a bottom-up approach, were extrapolated to the population level based on the most robust epidemiological estimates available for the Australian population. What are the implications for practitioners? Population screening programs have been widely suggested as an approach to reduce clinical penetrance; however, the lack of high-quality economic analyses has been cited as a barrier to implementation. The present study provides the most robust cost estimates to date, which may be used to populate economic models. In addition, the present study illustrates that reducing clinical penetrance of haemochromatosis is likely to result in substantial reductions in cost.

The impact of multiple sclerosis severity on health state utility values: Evidence from Australia

Background:

The measurement of health state utility values (HSUVs) for a representative sample of Australian people with multiple sclerosis (MS) has not previously been performed.

Objectives:

Our main aim was to quantify the HSUVs for different levels of disease severities in Australian people with MS.

Method:

HSUVs were calculated by employing a ‘judgement-based’ method that essentially creates EQ-5D-3L profiles based on WHOQOL-100 responses and then applying utility weights to each level in each dimension. A stepwise linear regression was used to evaluate the relationship between HSUVs and disease severity, classified as mild (Expanded Disability Status Scale (EDSS) levels: 0–3.5), moderate (EDSS levels: 4–6) and severe (EDSS levels: 6.5–9.5).

Results:

Mean HSUV for all people with MS was 0.53 (95% confidence interval (CI): 0.52–0.54). Utility decreased with increasing disease severity: 0.61 (95% CI: 0.60–0.62), 0.51 (95% CI: 0.50–0.52) and 0.40 (95% CI: 0.38–0.43) for mild, moderate and severe disease, respectively. Adjusted differences in mean HSUV between the three severity groups were statistically significant.

Conclusion:

For the first time in Australia, we have quantified the impact of increasing severity of MS on health utility of people with MS. The HSUVs we have generated will be useful in further health economic analyses of interventions that slow progression of MS.

The interaction of excited atoms and few-cycle laser pulses

This work describes the first observations of the ionisation of neon in a metastable atomic state utilising a strong-field, few-cycle light pulse. We compare the observations to theoretical predictions based on the Ammosov-Delone-Krainov (ADK) theory and a solution to the time-dependent Schrödinger equation (TDSE). The TDSE provides better agreement with the experimental data than the ADK theory. We optically pump the target atomic species and measure the ionisation rate as the a function of different steady-state populations in the fine structure of the target state which shows significant ionisation rate dependence on populations of spin-polarised states. The physical mechanism for this effect is unknown.

Diverse approaches to the health economic evaluation of bariatric surgery: a comprehensive systematic review

BACKGROUND

Health economic evaluations inform healthcare resource allocation decisions for treatment options for obesity including bariatric/metabolic surgery. As an important advance on existing systematic reviews, we aimed to capture, summarize and synthesize a diverse range of economic evaluations on bariatric surgery.

METHODS

Studies were identified by electronic screening of all major biomedical/economic databases. Studies included if they reported any quantified health economic cost and/or consequence with a measure of effect for any type of bariatric surgery from 1995 to September 2015. Study screening, data extraction and synthesis followed international guidelines for systematic reviews.

RESULTS

Six thousand one hundred eighty-seven studies were initially identified. After two levels of screening, 77 studies representing 17 countries (56% USA) were included. Despite study heterogeneity, common themes emerged, and important gaps were identified. Most studies adopted the healthcare system/third-party payer perspective; reported costs were generally healthcare resource use (inpatient/shorter-term outpatient). Out-of-pocket costs to individuals, family members (travel time, caregiving) and indirect costs due to lost productivity were largely ignored. Costs due to reoperations/complications were not included in one-third of studies. Body-contouring surgery included in only 14%. One study evaluated long-term waitlisted patients. Surgery was cost-effective/cost-saving for severely obese with type 2 diabetes mellitus. Study quality was inconsistent.

DISCUSSION

There is a need for studies that assume a broader societal perspective (including out-of-pocket costs, costs to family and productivity losses) and longer-term costs (capture reoperations/complications, waiting, body contouring), and consequences (health-related quality-of-life). Full economic evaluation underpinned by reporting standards should inform prioritization of patients (e.g. type 2 diabetes mellitus with body mass index 30 to 34.9 kg/m(2) or long-term waitlisted) for surgery. © 2016 World Obesity.

Review: PROactive 03: Pioglitazone, type 2 diabetes and reducing macrovascular events — economic implications?

conomic value of medicines, medical devices and other technologies is an increasingly important consideration in healthcare management. Conducting high quality economic analyses alongside randomised controlled clinical trials (RCTs) is desirable since these offer timely information with high internal validity. The recent publication of the landmark PROactive study provides a relevant platform upon which to base a detailed economic evaluation of the possible additional benefit of pioglitazone over and above current best treatment in patients with type 2 diabetes with severe cardiovascular (CV) disease. Pioglitazone improved CV outcome and reduced the need to add insulin to existing therapy in individuals at high risk of further macrovascular events. The predefined economic analysis of this study using well-accepted methods will inform the cost effectiveness (CE) of pioglitazone confirming (or not) its value in the management of patients with type 2 diabetes with severe CV disease.

The relationship between return on investment and quality of study methodology in workplace health promotion programs

OBJECTIVE

To determine the relationship between return on investment (ROI) and quality of study methodology in workplace health promotion programs.

DATA SOURCE

Data were obtained through a systematic literature search of National Health Service Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Database (HTA), Cost Effectiveness Analysis (CEA) Registry, EconLit, PubMed, Embase, Wiley, and Scopus.

STUDY INCLUSION AND EXCLUSION CRITERIA

Included were articles written in English or German reporting cost(s) and benefit(s) and single or multicomponent health promotion programs on working adults. Return-to-work and workplace injury prevention studies were excluded.

DATA EXTRACTION

Methodological quality was graded using British Medical Journal Economic Evaluation Working Party checklist. Economic outcomes were presented as ROI.

DATA SYNTHESIS

ROI was calculated as ROI = (benefits - costs of program)/costs of program. Results were weighted by study size and combined using meta-analysis techniques. Sensitivity analysis was performed using two additional methodological quality checklists. The influences of quality score and important study characteristics on ROI were explored.

RESULTS

Fifty-one studies (61 intervention arms) published between 1984 and 2012 included 261,901 participants and 122,242 controls from nine industry types across 12 countries. Methodological quality scores were highly correlated between checklists (r = .84-.93). Methodological quality improved over time. Overall weighted ROI [mean ± standard deviation (confidence interval)] was 1.38 ± 1.97 (1.38-1.39), which indicated a 138% return on investment. When accounting for methodological quality, an inverse relationship to ROI was found. High-quality studies (n = 18) had a smaller mean ROI, 0.26 ± 1.74 (.23-.30), compared to moderate (n = 16) 0.90 ± 1.25 (.90-.91) and low-quality (n = 27) 2.32 ± 2.14 (2.30-2.33) studies. Randomized control trials (RCTs) (n = 12) exhibited negative ROI, -0.22 ± 2.41(-.27 to -.16). Financial returns become increasingly positive across quasi-experimental, nonexperimental, and modeled studies: 1.12 ± 2.16 (1.11-1.14), 1.61 ± 0.91 (1.56-1.65), and 2.05 ± 0.88 (2.04-2.06), respectively.

CONCLUSION

Overall, mean weighted ROI in workplace health promotion demonstrated a positive ROI. Higher methodological quality studies provided evidence of smaller financial returns. Methodological quality and study design are important determinants.

Screening for osteoporosis in Chinese post-menopausal women: a health economic modelling study

Screening and appropriate treatment for osteoporosis has been proven to be cost-effective in many populations; however, it is not clear in the Chinese population. Simulations using a validated health economics model suggest that screening for osteoporosis in Chinese women is cost-effective and may even be cost-saving in Chinese post-menopausal women.

INTRODUCTION

This study aimed at determining the cost-effectiveness of osteoporosis screening strategies in post-menopausal Chinese women.

METHODS

A validated state-transition microsimulation model with a lifetime horizon was used to evaluate the cost-effectiveness of different screening strategies with treatment of alendronate compared with current osteoporosis management in China. Osteoporosis screening strategies assessed were (1) universal screening with dual-energy X-ray absorptiometry (DXA) alone; (2) Osteoporosis Self-Assessment Tool for Asians (OSTA) + DXA; and (3) quantitative ultrasound (QUS) + DXA with rescreening at 2, 5 or 10-year intervals for patients screened negative by DXA. The study was performed from the Chinese healthcare payer's perspective. All model inputs were retrieved from publically available literature. Uncertainties were addressed by one-way and probabilistic sensitivity analysis.

RESULTS

Screening strategies all improved clinical outcomes at increased costs, and each were cost-effective compared with no screening in women aged 55 years given the Chinese willingness-to-pay threshold of USD 20,000 per quality-adjusted life year (QALY) gained. Pre-screening with QUS and subsequent DXA screening if the QUS T-score ≤ -0.5 with a 2-year rescreening interval was the most cost-effective strategy with the highest probability of being cost-effective across all non-dominated strategies. Screening strategies were cost-saving if screenings were initiated from age 65 years. One-way sensitivity analyses indicated that the results were robust.

CONCLUSIONS

Pre-screening with QUS with subsequent DXA screening if the QUS T-score ≤ -0.5 with a 2-year rescreening interval in the Chinese women starting at age 55 is the most cost-effective. In addition, screening and treatment strategies are cost-saving if the screening initiation age is greater than 65 years.

Recent trends in life expectancy for people with type 1 diabetes in Sweden

AIMS/HYPOTHESIS

People with type 1 diabetes have reduced life expectancy (LE) compared with the general population. Our aim is to quantify mortality changes from 2002 to 2011 in people with type 1 diabetes in Sweden.

METHODS

This study uses health records from the Swedish National Diabetes Register (NDR) linked with death records. Abridged period life tables for those with type 1 diabetes aged 20 years and older were derived for 2002-06 and 2007-11 using Chiang's method. Cox proportional hazard models were used to assess trends in overall and cause-specific mortality.

RESULTS

There were 27,841 persons aged 20 years and older identified in the NDR as living with type 1 diabetes between 2002 and 2011, contributing 194,685 person-years of follow-up and 2,018 deaths. For men with type 1 diabetes, the remaining LE at age 20 increased significantly from 47.7 (95% CI 46.6, 48.9) in 2002-06 to 49.7 years (95% CI 48.9, 50.6) in 2007-11. For women with type 1 diabetes there was no significant change, with an LE at age 20 of 51.7 years (95% CI 50.3, 53.2) in 2002-06 and 51.9 years (95% CI 50.9, 52.9) in 2007-11. Cardiovascular mortality significantly reduced, with a per year HR of 0.947 (95% CI 0.917, 0.978) for men and 0.952 (95% CI 0.916, 0.989) for women.

CONCLUSIONS/INTERPRETATION

From 2002-06 to 2007-11 the LE at age 20 of Swedes with type 1 diabetes increased by approximately 2 years for men but minimally for women. These recent gains have been driven by reduced cardiovascular mortality.

The new Australian after-hours general practice incentive payment mechanism: equity for rural general practice?

In July 2015, a national scheme for after-hours incentive funding for general practices was re-introduced in Australia, 2-years after funding was transferred to regional primary health care organisations (Medicare Locals). The re-introduction was recommended in a 2014 review of after-hours primary care reflecting the "overwhelming desire" among general practice. Given the centrality of after-hours care provision in rural and remote practices identified in the review, we compare and contrast the current and historical after-hours incentive funding mechanisms focussing on fairness towards rural general practices. While there are similarities between the current and historical mechanisms, significant differences exist. The comparison is not straightforward. The major consistency is utilisation of practice standardised whole patient equivalents (SWPE) as the basis of funding, inherently favouring large urban general practices. This bias is expected to increase given a shift in focus from practices with no option but to provide 24/7 care to any practice providing 24/7 care; and an associated increased funding per SWPE. Differences primarily pertain to classification processes, in which the realities of rural service provision and recognition of regional support mechanisms are given minimal consideration. Rapid introduction of the new general practice after-hours incentive funding mechanism has led to inconsistencies and has exacerbated inherent biases, particularly inequity towards rural providers. Impact on morale and service provision in non-urban areas should be monitored.

Risk assessment in acute non-variceal upper GI bleeding: the AIMS65 score in comparison with the Glasgow-Blatchford score in a Scottish population

INTRODUCTION

The early use of risk stratification scores is recommended for patients presenting with acute non-variceal upper gastrointestinal (GI) bleeds (ANVGIB). AIMS65 is a novel, recently derived scoring system, which has been proposed as an alternative to the more established Glasgow-Blatchford score (GBS).

OBJECTIVE

To validate the AIMS65 scoring system in a predominantly Caucasian population from Scotland and compare it with the GBS.

DESIGN

Retrospective study of patients presenting to a district general hospital in Scotland with a suspected diagnosis of ANVGIB who underwent inpatient upper GI endoscopy between March 2008 and March 2013.

OUTCOMES

The primary outcome measure was 30-day mortality. Secondary outcome measures were requirement for endoscopic intervention, endoscopy refractory bleeding, blood transfusion, rebleeding and admission to high dependency unit (HDU) and intensive care unit (ICU). The area under the receiver operating characteristic (AUROC) curve was calculated for each score.

RESULTS

328 patients were included. Of these 65.9% (n=216) were men and 34.1% (n=112) women. The mean age was 65.2 years and 30-day mortality 5.2%. AIMS65 was superior to the GBS in predicting mortality, with an AUROC of 0.87 versus 0.70 (p<0.05). The GBS was superior for blood transfusion (AUROC 0.84 vs 0.62, p<0.05) and admission to HDU (AUROC 0.73 vs 0.62, p<0.05). There were no significant differences between the scores with respect to requirement for endoscopic intervention, endoscopy refractory bleeding, rebleeding and admission to ICU.

CONCLUSIONS

AIMS65 accurately predicted mortality in a Scottish population of patients with ANVGIB. Large prospective studies are now required to establish the exact role of AIMS65 in triaging patients with ANVGIB.

Quality of life utility values for hereditary haemochromatosis in Australia

Background

Hereditary hemochromatosis (HH) is a common autosomal recessive disorder amongst persons of northern European heritage. If untreated, iron accumulates in parenchymal tissues causing morbidity and mortality. As diagnosis often follows irreversible organ damage, screening programs have been suggested to increase early diagnosis. A lack of economic evidence has been cited as a barrier to establishing such a program. Previous analyses used poorly estimated utility values. This study sought to measure utilities directly from people with HH in Australia.

Methods

Volunteers with HH were recruited to complete a web-based survey. Utility was assessed using the Assessment of Quality of Life 4D (AQOL-4D) instrument. Severity of HH was graded into four categories. Multivariable regression analysis was performed to identify parameters associated with HSUV.

Results

Between November 2013 and November 2014, 221 people completed the survey. Increasing severity of HH was negatively associated with utility. Mean (standard deviation) utilities were 0.76 (0.21), 0.81 (0.18), 0.60 (0.27), and 0.50 (0.27) for categories 1–4 HH respectively. Lower mean utility was found for symptomatic participants (categories 3 and 4) compared with asymptomatic participants (0.583 v. 0.796). Self-reported HH-related symptoms were negatively associated with HSUV (r = −0.685).

Conclusions

Symptomatic stages of HH and presence of multiple self-reported symptoms were associated with decreasing utility. Previous economic analyses have used higher utilities which likely resulted in underestimates of the cost effectiveness of HH interventions. The utilities reported in this paper are the most robust available, and will contribute to improving the validity of future economic models for HH.

Assessing equity in benefit distribution of government health subsidy in 2012 across East China: benefit incidence analysis

Background

Improving the equitable benefit distribution of government health subsidies, particularly among the country’s poorer socioeconomic groups, is a major goal of China’s healthcare sector reform.

Methods

Benefit incidence analysis was employed to measure the distribution of government health subsidies by income quintile. The concentration index (CI) of different levels of health care facility in urban and rural areas was calculated. A household survey complete through multistage stratified sampling was conducted in 2013 in urban areas (16,908 respondents) and rural areas (19,525 respondents).

Results

The overall CI for urban patients was 0.1068 for outpatient care and 0.1237 for inpatient care. For outpatient care, the CI was 0.0795, 0.0465 and 0.3456, respectively, at primary, secondary and tertiary health care facilities; for inpatient care, the CI was −0.2179, 0.0752 and 0.2883 at the corresponding facility levels. The overall CI for rural outpatients was −0.0659 and 0.0036 for inpatients. For outpatient care, the CI was −0.0818, 0.0567 and 0.0271 at primary, secondary and tertiary facilities, respectively; for inpatient care, the CI was −0.0050, 0.0084 and 0.0252 at the corresponding facility levels.

Conclusions

China’s primary level health care facilities were found to have a more equitable benefit distribution of government health subsidies than the secondary- and tertiary- level facilities. Increased government budget allocations and insurance imbursement rates, and the provision of technical support and qualified medical staff to lower-level hospitals were key factors. However, the provision of equal subsidies to all socioeconomic levels was found to be a potential threat to the equity of government health subsidy distribution.

Cost-effectiveness of raloxifene in the treatment of osteoporosis in Chinese postmenopausal women: impact of medication persistence and adherence

AIMS

Raloxifene treatment of osteoporotic fractures is clinically effective, but economic evidence in support of raloxifene reimbursement is lacking in the People's Republic of China. We aimed at evaluating the cost-effectiveness of raloxifene in the treatment of osteoporotic fractures using an osteoporosis health economic model. We also assessed the impact of medication persistence and adherence on clinical outcomes and cost-effectiveness of raloxifene.

METHODS

We used a previously developed and validated osteoporosis state-transition microsimulation model to compare treatment with raloxifene with current practices of osteoporotic fracture treatment (conventional treatment) from the health care payer's perspective. A Monte Carlo probabilistic sensitivity analysis with microsimulations was conducted. The impact of medication persistence and adherence on clinical outcomes and the cost-effectiveness of raloxifene was addressed in sensitivity analyses. The simulated patients used in the model's initial state were 65-year-old postmenopausal Chinese women with osteoporosis (but without previous fractures), simulated using a 1-year cycle length until all patients had died. Costs were presented in 2015 US dollars (USD), and costs and effectiveness were discounted at 3% annually. The willingness-to-pay threshold was set at USD 20,000 per quality-adjusted life year (QALY) gained.

RESULTS

Treatment with raloxifene improved clinical effectiveness by 0.006 QALY, with additional costs of USD 221 compared with conventional treatment. The incremental cost-effectiveness ratio was USD 36,891 per QALY gained. The cost-effectiveness decision did not change in most of the one-way sensitivity analyses. With full raloxifene persistence and adherence, average effectiveness improved compared with the real-world scenario, and the incremental cost-effectiveness ratio was USD 40,948 per QALY gained compared with conventional treatment.

CONCLUSION

Given the willingness-to-pay threshold, raloxifene treatment was not cost-effective for treatment of osteoporotic fractures in postmenopausal Chinese women. Medication persistence and adherence had a great impact on clinical- and cost-effectiveness, and therefore should be incorporated in future pharmacoeconomic studies of osteoporosis interventions.

Australian insurance costs of jockeys injured in a race-day fall

BACKGROUND

The risk of falls and injuries in horseracing varies with sex and experience of the jockey.

AIMS

To determine whether the incidence and costs of insurance claims also differ by such factors.

METHODS

A retrospective analysis of compensation claims by flat racing and jumps jockeys injured in a race-day fall in Australia between 2002 and 2009. Claim incidence, costs, absentee days and location, cause and type of injury sustained were described, stratified by jockey sex, age and experience.

RESULTS

The incidence of claims by flat and jumps racing was 0.6 and 6.5 per 1000 rides, respectively. The mean cost of a claim was 43374 Australian dollars (AUD) (SD 249612) in flat racing and AUD 52589 (SD 157808) in jumps racing. The incidence of claims was greater for experienced flat racing jockeys than apprentices but mean costs were higher for apprentices. After adjustment for experience, there were no sex differences in the average cost or incidence of flat racing jockeys' claims. In general, the fall incidence declined, but the claim incidence and median cost of a claim increased, with age. On average, jockeys were absent from work for 9 weeks following a substantive injury. Limb fractures (33%), muscular or soft tissue injuries (28%) and contusions (17%) were the most commonly reported injuries.

CONCLUSIONS

The economic costs of jockey injuries sustained in race-day falls are considerable. Identification of differences in incidence and costs of insurance claims between jockey characteristics will assist decision makers in the development and assessment of targeted safety strategies.

A Systematic Review and Narrative Synthesis of Health Economic Studies Conducted for Hereditary Haemochromatosis

BACKGROUND

Hereditary haemochromatosis (HH) is a common genetic condition amongst people of northern European heritage. HH is associated with increased iron absorption leading to parenchymal organ damage and multiple arthropathies. Early diagnosis and treatment prevents complications. Population screening may increase early diagnosis, but no programmes have been introduced internationally: a paucity of health economic data is often cited as a barrier.

OBJECTIVE

To conduct a systematic review of all health economic studies in HH.

METHODS

Studies were identified through electronic searching of economic/biomedical databases. Any study on HH with original economic component was included. Study quality was formally assessed. Health economic data were extracted and analysed through narrative synthesis.

RESULTS

Thirty-eight studies met the inclusion criteria. The majority of papers reported on costs or cost effectiveness of screening programmes. Whilst most concluded screening was cost effective compared with no screening, methodological flaws limit the quality of these findings. Assumptions regarding clinical penetrance, effectiveness of screening, health-state utility values (HSUVs), exclusion of early symptomatology (such as fatigue, lethargy and multiple arthropathies) and quantification of costs associated with HH were identified as key limitations. Treatment studies concluded therapeutic venepuncture was the most cost-effective intervention.

CONCLUSIONS

There is a paucity of high-quality health economic studies relating to HH. The development of a comprehensive HH cost-effectiveness model utilising HSUVs is required to determine whether screening is worthwhile.

Development of the Workplace Health Savings Calculator: a practical tool to measure economic impact from reduced absenteeism and staff turnover in workplace health promotion

Background

Workplace health promotion is focussed on improving the health and wellbeing of workers. Although quantifiable effectiveness and economic evidence is variable, workplace health promotion is recognised by both government and business stakeholders as potentially beneficial for worker health and economic advantage. Despite the current debate on whether conclusive positive outcomes exist, governments are investing, and business engagement is necessary for value to be realised. Practical tools are needed to assist decision makers in developing the business case for workplace health promotion programs. Our primary objective was to develop an evidence-based, simple and easy-to-use resource (calculator) for Australian employers interested in workplace health investment figures.

Results

Three phases were undertaken to develop the calculator. First, evidence from a literature review located appropriate effectiveness measures. Second, a review of employer-facilitated programs aimed at improving the health and wellbeing of employees was utilised to identify change estimates surrounding these measures, and third, currently available online evaluation tools and models were investigated. We present a simple web-based calculator for use by employers who wish to estimate potential annual savings associated with implementing a successful workplace health promotion program. The calculator uses effectiveness measures (absenteeism and staff turnover rates) and change estimates sourced from 55 case studies to generate the annual savings an employer may potentially gain. Australian wage statistics were used to calculate replacement costs due to staff turnover. The calculator was named the Workplace Health Savings Calculator and adapted and reproduced on the Healthy Workers web portal by the Australian Commonwealth Government Department of Health and Ageing.

Conclusion

The Workplace Health Savings Calculator is a simple online business tool that aims to engage employers and to assist participation, development and implementation of workplace health promotion programs.

Workplace Injuries in Thoroughbred Racing: An Analysis of Insurance Payments and Injuries amongst Jockeys in Australia from 2002 to 2010

BACKGROUND

There is no comprehensive study of the costs of horse-related workplace injuries to Australian Thoroughbred racing jockeys.

OBJECTIVES

To analyse the characteristics of insurance payments and horse-related workplace injuries to Australian jockeys during Thoroughbred racing or training.

METHODS

Insurance payments to Australian jockeys and apprentice jockeys as a result of claims for injury were reviewed. The cause and nature of injuries, and the breakdown of payments associated with claims were described.

RESULTS

The incidence of claims was 2.1/1000 race rides, with an average cost of AUD 9 million/year. Race-day incidents were associated with 39% of claims, but 52% of the total cost. The mean cost of race-day incidents (AUD 33,756) was higher than non-race day incidents (AUD 20,338). Weekly benefits and medical expenses made up the majority of costs of claims. Fractures were the most common injury (29.5%), but head injuries resulting from a fall from a horse had the highest mean cost/claim (AUD 127,127).

CONCLUSIONS

Costs of workplace injuries to the Australian Thoroughbred racing industry have been greatly underestimated because the focus has historically been on incidents that occur on race-days. These findings add to the evidence base for developing strategies to reduce injuries and their associated costs.

Projection of osteoporosis-related fractures and costs in China: 2010-2050

A state-transition microsimulation model was used to project the substantial economic burden to the Chinese healthcare system of osteoporosis-related fractures. Annual number and costs of osteoporosis-related fractures were estimated to double by 2035 and will increase to 5.99 (95 % CI 5.44, 6.55) million fractures costing $25.43 (95 % CI 23.92, 26.95) billion by 2050. Consequently, cost-effective intervention policies must urgently be identified in an attempt to minimize the impact of fractures.

INTRODUCTION

The aim of the study was to project the osteoporosis-related fractures and costs for the Chinese population aged ≥50 years from 2010 to 2050.

METHODS

A state-transition microsimulation model was used to simulate the annual incident fractures and costs. The simulation was performed with a 1-year cycle length and from the Chinese healthcare system perspective. Incident fractures and annual costs were estimated from 100 unique patient populations for year 2010, by multiplying the age- and sex-specific annual fracture risks and costs of fracture by the corresponding population totals in each of the 100 categories. Projections for 2011-2050 were performed by multiplying the 2010 risks and costs of fracture by the respective annual population estimates. Costs were presented in 2013 US dollars.

RESULTS

Approximately 2.33 (95 % CI 2.08, 2.58) million osteoporotic fractures were estimated to occur in 2010, costing $9.45 (95 % CI 8.78, 10.11) billion. Females sustained approximately three times more fractures than males, accounting for 76 % of the total costs from 1.85 (95 % CI 1.68, 2.01) million fractures. The annual number and costs of osteoporosis-related fractures were estimated to double by 2035 and will increase to 5.99 (95 % CI 5.44, 6.55) million fractures costing $25.43 (95 % CI 23.92, 26.95) billion by 2050.

CONCLUSIONS

Our study demonstrated that osteoporosis-related fractures cause a substantial economic burden which will markedly increase over the coming decades. Consequently, healthcare resource planning must consider these increasing costs, and cost-effective screening and intervention policies must urgently be identified in an attempt to minimize the impact of fractures on the health of the burgeoning population as well as the healthcare budget.

Investigating the costs of major and minor cycling crashes in Tasmania, Australia

OBJECTIVE

A pilot study to estimate the societal costs of cycling crashes in Tasmania.

METHODS

A telephone-based questionnaire collected information on demographics, cycling habits and details of major and minor crashes. Costs were estimated from medical resource consumption, lost work and leisure time.

RESULTS

The survey was completed by 136 cyclists. Participants reported 59 major crashes in five years preceding the interview and 27 minor crashes in 12 months. Mean (standard deviation) costs/major crash were $12,499 ($14,301), including direct medical costs $2,569 ($4,523), direct non-medical costs $372 ($728), indirect costs of $6,027 ($10,092) and costs of lost leisure time $3,531 ($7,062). Costs/minor crashes were $632 ($795), including direct non-medical costs of $225 ($601), productivity losses of $117 ($210) and costs of lost leisure time $290 (622). Total annual costs of major cycling crashes in Tasmania were $4,239,097 ($4,850,255).

CONCLUSIONS

Indirect costs and costs due to lost leisure time are major contributors to the total societal costs. The comprehensive quantification of costs of crashes will inform decision makers formulating policies that improve the safety of cyclists leading to reductions in the economic burden on society.

Residual lifetime and 10 year absolute risks of osteoporotic fractures in Chinese men and women

OBJECTIVE

To determine the residual lifetime and 10 year absolute risks of osteoporotic fractures in Chinese men and women.

METHODS

A validated state-transition microsimulation model was used. Microsimulation and probabilistic sensitivity analyses were performed to address the uncertainties in the model. All parameters including fracture incidence rates and mortality rates were retrieved from published literature. Simulated subjects were run through the model until they died to estimate the residual lifetime fracture risks. A 10 year time horizon was used to determine the 10 year fracture risks. We estimated the risk of only the first osteoporotic fracture during the simulation time horizon.

RESULTS

The residual lifetime and 10 year risks of having the first osteoporotic (hip, clinical vertebral or wrist) fracture for Chinese women aged 50 years were 40.9% (95% CI: 38.3-44.0%) and 8.2% (95% CI: 6.8-9.3%) respectively. For men, the residual lifetime and 10 year fracture risks were 8.7% (95% CI: 7.5-9.8%) and 1.2% (95% CI: 0.8-1.7%) respectively. The residual lifetime fracture risks declined with age, whilst the 10 year fracture risks increased with age until the short-term mortality risks outstripped the fracture risks. Residual lifetime and 10 year clinical vertebral fracture risks were higher than those of hip and wrist fractures in both sexes.

CONCLUSIONS

More than one third of the Chinese women and approximately one tenth of the Chinese men aged 50 years are expected to sustain a major osteoporotic fracture in their remaining lifetimes. Due to increased fracture risks and a rapidly ageing population, osteoporosis will present a great challenge to the Chinese healthcare system.

LIMITATIONS

While national data was used wherever possible, regional Chinese hip and clinical vertebral fracture incidence rates were used, wrist fracture rates were taken from a Norwegian study and calibrated to the Chinese population. Other fracture sites like tibia, humerus, ribs and pelvis were not included in the analysis, thus these risks are likely to be underestimates. Fracture risk factors other than age and sex were not included in the model. Point estimates were used for fracture incidence rates, osteoporosis prevalence and mortality rates for the general population.

Screening for and treatment of osteoporosis: construction and validation of a state-transition microsimulation cost-effectiveness model

This study aimed to document and validate a new cost-effectiveness model of osteoporosis screening and treatment strategies. The state-transition microsimulation model demonstrates strong internal and external validity. It is an important tool for researchers and policy makers to test the cost-effectiveness of osteoporosis screening and treatment strategies.

INTRODUCTION

The objective of this study was to document and validate a new cost-effectiveness model of screening for and treatment of osteoporosis.

METHODS

A state-transition microsimulation model using a lifetime horizon was constructed with seven Markov states (no history of fractures, hip fracture, vertebral fracture, wrist fracture, other fracture, postfracture state, and death) describing the most important clinical outcomes of osteoporotic fractures. Tracker variables were used to record patients' history, such as fracture events, duration of treatment, and time since last screening. The model was validated for Chinese postmenopausal women receiving screening and treatment versus no screening. Goodness-of-fit analyses were performed for internal and external validation. External validity was tested by comparing life expectancy, osteoporosis prevalence rate, and lifetime and 10-year fracture risks with published data not used in the model.

RESULTS

The model represents major clinical facets of osteoporosis-related conditions. Age-specific hip, vertebral, and wrist fracture incidence rates were accurately reproduced (the regression line slope was 0.996, R(2) = 0.99). The changes in costs, effectiveness, and cost-effectiveness were consistent with changes in both one-way and probabilistic sensitivity analysis. The model predicted life expectancy and 10-year any major osteoporotic fracture risk at the age of 65 of 19.01 years and 13.7%, respectively. The lifetime hip, clinical vertebral, and wrist fracture risks at age 50 were 7.9, 29.8, and 18.7% respectively, all consistent with reported data.

CONCLUSIONS

Our model demonstrated good internal and external validity, ensuring it can be confidently applied in economic evaluations of osteoporosis screening and treatment strategies.

A meta-analysis of the relative risk of mortality for type 1 diabetes patients compared to the general population: exploring temporal changes in relative mortality

Aims

Type 1 diabetes has been associated with an elevated relative risk (RR) of mortality compared to the general population. To review published studies on the RR of mortality of Type 1 diabetes patients compared to the general population, we conducted a meta-analysis and examined the temporal changes in the RR of mortality over time.

Methods

Systematic review of studies reporting RR of mortality for Type 1 diabetes compared to the general population. We conducted meta-analyses using a DerSimonian and Laird random effects model to obtain the average effect and the distribution of RR estimates. Sub-group meta-analyses and multivariate meta-regression analysis was performed to examine heterogeneity. Summary RR with 95% CIs was calculated using a random-effects model.

Results

26 studies with a total of 88 subpopulations were included in the meta-analysis and overall RR of mortality was 3.82 (95% CI 3.41, 3.4.29) compared to the general population. Observations using data prior to 1971 had a much larger estimated RR (5.80 (95% CI 4.20, 8.01)) when compared to: data between; 1971 and 1980 (5.06 (95% CI 3.44, 7.45)); 1981–90 (3.59 (95% CI 3.15, 4.09)); and those after 1990 (3.11 (95% CI 2.47, 3.91)); suggesting mortality of Type 1 diabetes patients when compared to the general population have been improving over time. Similarly, females (4.54 (95% CI 3.79–5.45)) had a larger RR estimate when compared to males (3.25 (95% CI 2.82–3.73) and the meta-regression found evidence for temporal trends and sex (p<0.01) accounting for heterogeneity between studies.

Conclusions

Type 1 diabetes patients’ mortality has declined at a faster rate than the general population. However, the largest relative improvements have occurred prior to 1990. Emphasis on intensive blood glucose control alongside blood pressure control and statin therapy may translate into further reductions in mortality in coming years.

Severe hypoglycemia and mortality after cardiovascular events for type 1 diabetic patients in Sweden

OBJECTIVE

To examine whether previous severe hypoglycemic events were associated with the risk of all-cause mortality after major cardiovascular events (myocardial infarction [MI] or stroke) in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This study is based on data from the Swedish National Diabetes Register linked to patient-level hospital records, prescription data, and death records. We selected patients with type 1 diabetes who visited a clinic during 2002-2010 and experienced a major cardiovascular complication after their clinic visit. We estimated a two-part model for all-cause mortality after a major cardiovascular event: logistic regression for death within the first month and a Cox proportional hazards model conditional on 1-month survival. At age 60 years, 5-year cumulative mortality risk was estimated from the models for patients with and without prior diabetes complications.

RESULTS

A total of 1,839 patients experienced major cardiovascular events, of whom 403 had previously experienced severe hypoglycemic events and 703 died within our study period. A prior hypoglycemic event was associated with a significant increase in mortality after a cardiovascular event, with hazard ratios estimated at 1.79 (95% CI 1.37-2.35) within the first month and 1.25 (95% CI 1.02-1.53) after 1 month. Patients with prior hypoglycemia had an estimated 5-year cumulative mortality risk of 52.4% (95% CI 45.3-59.5) and 39.8% (95% CI 33.4-46.3) for MI and stroke, respectively.

CONCLUSIONS

We have found evidence that patients with type 1 diabetes in Sweden with prior severe hypoglycemic events have increased risk of mortality after a cardiovascular event.

Projected Worldwide Disease Burden from Giant Cell Arteritis by 2050

Objective.

To estimate and project the number of people affected worldwide by giant cell arteritis (GCA) by 2050. Modeling the number of people visually impaired as a result of this disease will help establish the projected morbidity and resource burden.

Methods.

A systematic literature review up to December 2013 was conducted using PubMed and ISI Web of Science. Studies reporting an incidence rate for GCA were used to model disease incident cases at regional and national levels. United Nations Population Prospect data were used for population projections. Morbidity burden was established through rates of visual impairment. The associated financial implications were calculated for the United States.

Results.

The number of incident cases of GCA will increase secondary to an aging population. By 2050, more than 3 million people will have been diagnosed with GCA in Europe, North America, and Oceania. About 500,000 people will be visually impaired. By 2050, in the United States alone, the estimated cost from visual impairment due to GCA will exceed US$76 billion. Inpatient care for patients with active GCA will total about US$1 billion. Management of steroid-related adverse events will increase costs further, with steroid-induced fractures estimated to total US$6 billion by 2050.

Conclusion.

Projecting disease burden for GCA on a global scale allows for optimization of healthcare planning and prioritization of research domains. Additional population-based studies are required to more accurately project worldwide disease burden. Our work highlights the future global disease burden of GCA, and illustrates the associated financial implications.

Accident rates amongst regular bicycle riders in Tasmania, Australia

PURPOSE

To characterise the demographics, cycling habits and accident rates of adult cyclists in Tasmania.

METHODS

Volunteers ≥18 years of age who had cycled at least once/week over the previous month provided information on demographics; cycling experience; bicycles owned; hours/km/trips cycled per week; cycling purpose; protective equipment used; and major (required third-party medical treatment or resulted ≥1 day off work) or minor (interfered with individuals' regular daily activities and/or caused financial costs) accidents while cycling.

RESULTS

Over 8-months, 136 cyclists (70.6% male) completed the telephone survey. Mean (standard deviation) age was 45.4 (12.1) years with 17.1 (11.4) years of cycling experience. In the week prior to interview, cyclists averaged 6.6 trips/week (totalling 105.7km or 5.0h). The most common reason for cycling was commuting/transport (34% of trips), followed by training/health/fitness (28%). The incidence of major and minor cycling accidents was 1.6 (95% CI 1.1-2.0) and 3.7 (2.3-5.0) per 100,000km, respectively. Male sex was associated with a significantly lower minor accident risk (incidence rate ratio=0.34, p=0.01). Mountain biking was associated with a significantly higher risk of minor accident compared with road or racing, touring, and city or commuting biking (p<0.05).

CONCLUSIONS

Physical activity of regular cyclists' exceeds the level recommended for maintenance of health and wellbeing; cyclists also contributed substantially to the local economy. Accident rates are higher in this sample than previously reported in Tasmania and internationally. Mountain biking was associated with higher risks of both major and minor accidents compared to road/racing bike riding.